Schedule of external assurances - reviews, accreditations, audits and benchmarks
SCHEDULE OF EXTERNAL ASSURANCES RECEIVED Received (RAG status)
Overseeing Committee (s)
Where Assurance is not positive, a
Current status February
Last visit / assessment
brief narrative as to action required
Previous 3 years
and by whom or reference to action
April - June 09
Lead Manager
July - Sept 09
CQC outcome
Sept - Dec 09
Lead Director
Jan - Mar 09
Jan - Mar 10
Department
CRR ref No
plan
Division
Assurance
10
Area of Assurance Comments
Provided By
CQC Hygiene Code 10/21/2009 Trust wide All T H 2 8 Final report received. No concerns. STICC Action plan monitored as part of
Rowson Coleman TB G G G Health Act Action Plan
CQC Staff opinion survey Mar-09 Trust wide all J Clarke W Wraith 12,13, Scores show year on year improvement ME Action plans monitored by ME and
14 A A A OD/Workforce group
CQC Maternity services 2008 1 W&C T C Smith 1 National maternity survey - SATH 'best Div 2
Rowson performing' Trust in Central England G G
CQC/Picker Inpatients Mar-09 Trust wide all J Clarke C Jowett 1 Annual National Inpatient survey CGE Action plan in place monitored
Institute ME TB A A A through Patient Experience Report
CQC/Picker Emergency care Jan-09 Div 1 A&E J Clarke Fiona 1 A&E survey - carried out 2 - 3 yearly CGE to ME and TB of poor areas of
repeat survey
Institute Lennan ME TB A A A practice to be carried out during
June 09
Audit ALE Oct-09 Trust all J Clarke C Jowett 16 Improved position: all areas scored 3 AC ME
Commission wide TB A G G
HSE Stress 28/30 Jan Trust wide all J Clarke K Titley 28 ,78 12,13, Review in relation to HSE Stress H&S Action plan monitored by H&S and
14 management standards ME Divisions
08 R A
HSE COSHH - Microbiology 7/17/2008 Div 3 Micro T S Blundell 12,13, 4 recommendations made - all actioned H&S Lone worker outstanding - but
Rowson 14 interim arrangements in place and
A G plan to issue devices by 03.09
HSE Dermatitis 21/22 Oct Trust wide all J Clarke C Jowett 12,13, 1 weeks notice: part of national review for H&S Action plan monitored by H&S
08 14 HC - no formal report but feedback G G Committee and rec tracking
HSE Stress 2/6/2009 Trust wide all J Clarke K Titley 12,13, received to previous HSE visit
Follow up H&S Notified of intention to revist in one
14 A A A year
HSE Follow up of electrical 10/21/2009 Estates estates T C 10 No concerns expressed H&S n/a
failure Rowson Needham G
HSE Microbiology CL3 labs 17&18 Jul 3 Pathology T Sue Howe 10 Div 3
2008 Rowson G G
NPSA PEAT Feb-09 Trust wide all T J Yale 10 Excellent all categories ME TB
Rowson G G G
MHRA Blood Bank PRH 6/26/2007 3 Pathology T C Crosby 10 some non compliances but good progress ME /
Rowson made CGE A G
MHRA Blood Bank RSH 2/28/2008 3 Pathology T C Crosby 10 No Critical non-compliances, several major ME / Action plan monitored by Div 3
Rowson CGE A G Board - almost complete
MHRA Pharmacy Jan-07 3 Pharmacy S Evans B McElroy 9 GMP Div 3
A G
Deanery PMETB Nov-08 Trust wide all S Evans T 12,13, Survey of junior drs in training Educatio
Crichlow 14 n ctte A A R R A
WM Deanery - Post graduate medical Apr-09 Trust wide all S Evans T 12,13, PG education QA Educatio
visit education Crichlow/ 14 n ctte A A
P Hipkiss
West renal services Sept 29 09 Jan-00 Renal T P Gordon 1 peer review ME
Midlands Rowson Action plan submitted to SHA -
Review A monitored by ME
Service
HealthESoluti Staff wellbeing (stress) May-08 Trust wide all J Clarke K Titley 28, 78 12,13, ME Action plans monitored by ME and
ons survey 14 A A OD/Workforce group
LCFS Compound Indicator Apr-09 Trust wide all S Tony Counter Fraud Arrangements - agency AC Action plans monitored by
Shanaha Brown R R
Assessments - HCC workers recommendation tracking
SHA RA5 - readiness Nov-08 Corp HR n Clarke W Wraith
J ME
assessment for ESR
G G
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Schedule of external assurances - reviews, accreditations, audits and benchmarks
DWP Disability tick Jul-08 Corp HR J Clarke W Wraith 1 ME
G G
T&W Council Catering Oct-08 Corp facilities T J Yale 5 Platinum award for healthy eating ME
Rowson G G
Internal Audit Library services Mar-06 Corp library J A O'Neil 12 Level 3 accreditation CGE
Buckley G G
OFSTED Joint Area Review - Mar-08 2 W&C T A Wood 7 Div 2
Children's Services Rowson Board G G
OFSTED Joint Area Review - May-08 2 W&C T A Wood 7 /ME
ME Minor recommendations relating to
Children's Services T&W Rowson A G training - being addressed
Healthcare Children's Services Mar-09 2 All T A Wood 7 ME Overarching action plan for
Commission Rowson CGE A A A children's services to be developed
by A Wood
CNST Maternity risk mangement Jun-07 2 W&C S Evans C Smith all Maternity level 3 achieved CGE
standards (clinical) G G
NHSLA General Risk Management Dec-08 Corp Corp J Clarke C Jowett all Level 2 achieved CGE Action plan developed - to CGE
Standards G G Jan 09
Local Midwifery - LSA Annual Apr-09 2 W&C T C Smith 12,13, CGE
Supervisory Inspection Rowson 14
G G G
Authority
HFEA Fertility Service Visit May 08 2 W&C T C Smith 1, 2 Report received - relicenced for 5 years Div 2
Licence Oct Rowson with no additional conditions G G
08
Sentinel audit Stroke Audit Jan-00 1 General T J Bennion 49 4 Div 1 Action plan monitored by Div 1 with
Medicine Rowson ME R A updates to CGE
Cancer Peer Cancer Services Autumn 09 2 Cancer T A 4 Self assessment Div 2 Action plan monitored by Div 2 and
Review services Rowson Trumper Skin Board ME
Urology /ME
Breast
A A
Upper GI
Lung
Chemotherapy
Regional QA Pharmacy - RSH Feb-08 3 Pharmacy S Evans B McElroy 4 9 Farwell audit Div 3
G G
Royal Pharmacy Aug-09 3 Pharmacy S Evans B McElroy 9 Unannounced inspection - controlled drugs Div 3
Pharmaceutical and registratable activities G G G
Society
URS Medical engineering 1/17/2008 3 MES T R 11 ISO 9001:2000 & ISO 13485 Div 3
Rowson Steventon G G
URS Medical engineering May-08 3 MES T R 11 ISO 9001:2000 & ISO 13485 Div 3
Rowson Steventon G G
URS Medical engineering 16.4.09 3 MES T R 11 upgraded ISO9000:2008 Standards
Rowson Steventon and further re-Certification to ISO
G G G
URS Medical engineering 9.2.10 3 MES T R 11 MES this time achieved the highest eleven (11) external audits
Rowson Steventon without a non-compliance
level of assessment with seven (7) G G
current status scores @ Level 1.
NHS Breast Breast screening 4/26/2006 3 Radiology S Evans J Fielding 11 Original visit made several Div 3 Action plan almost complete -
Screening recommendations A G monitored by CGE through
programme
JAG Endoscopy Oct-08 3 Endoscopy T L Atkin 11 Div 3
Rowson G G G
QA Cytology 3.10.09 1 Gynae / S Evans C Smith 11 awaiting report - positive feedback
Pathology received G G
CPA Microbiology 2/5/2008 3 Pathology S Evans C Crosby 11 Conditional approval of accreditation given ME
A G
CPA histology 3.8.09 3 Pathology S Evans C Crosby 11 Surveillance inspections
G G
CPA Cytology 3.9.09 3 Pathology S Evans C Crosby 11 Surveillance inspections
G G G
CPA Biochemistry 21.7.09 3 Pathology S Evans C Crosby 11 All outstanding issues cleared
A A G
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Schedule of external assurances - reviews, accreditations, audits and benchmarks
CPA Haematology /blood 21.7.09 - 3 Pathology S Evans C Crosby 11 All outstanding issues cleared ME
transfusion, 23.7.09 A A G G G
Deloittes Historic Due Diligence Jan 5 2009 Trust wide All D Vogler Tony Holt No reds TB n/a Action plan monitored by FT
A A programme Board
Concordat Risk Summit Oct-10 Trust all T Taylor all Some areas of concern ME n/a CQC assessing as part of
wide
G A A A registration process
Dr Foster HSMR Sep-09 Trust all S Evans C Jowett all England average but appears to be CGE,T Rebasing of Dr Foster Oct 09.
wide increasing B G G G G G R R
Alerts being investigated
CQC Quality and Risk Profile Jan-10 Trust all J Clarke C Jowett all Version 1 issued to inform registration Some areas of concern highlighted.
wide process A A Action plans in place.
SCHEDULE OF ASSURANCES - PLANNED VISITS etc
July - Sept 10
Lead Director
Jan - Mar 10
Oct - Dec 10
Apr - Jun 10
Future visit /
assessment
Department
CRR ref No
Overseeing
Committee
Healthcare
Manager
standard
Division
2011 or
beyond
Lead
Assurance
(s)
Area of Assurance Comments
Provided By
Audit ALE Jan - Mar 10 Trust wide all S 3 Part of Healthcare Standards AC ME
Commission Shanaha TB
n
HSE Stress Jan-10 Trust wide all J Helen 3 Follow up to previous HSE visit H&S
Buckley Smith
NPSA PEAT Trust wide all T J Yale 6 Cleanliness and food standards ME
Rowson
HCC Staff opinion Dec-09 Trust wide all J W Wraith 3 Annual staff opinion survey ME
Buckley
Picker Outpatients Dec-09 Trust wide All J Sam 4 national outpatient survey CGE
Institute / HC Buckley Foster ME
Second stage: historic Summer Trust wide All D Vogler Tony Holt 3 TB
due diligence 2010
Monitor FT assessment Autumn 10 Trust wide All D Vogler Tony Holt TB
HFEA Fertility Service 2013 2 Womens & T C Smith 1
Childrens Rowson
MHRA Medicines Manufacturing ? 2 Pharmacy S Evans B McElroy 1
NHSLA Maternity risk mangement Jun-10 2 Womens & S Evans Cathy 1,2 Maternity assessment - level to be agreed CGE
standards (clinical) Childrens Smith
WMQRS Urgent care Feb-10 1 S Evans P Skitt 1 took place Feb 10
WMQRS Critical Care 1
WMQRS Vascular Services 2
WMQRS Stroke 1
WMQRS Dementia 1
WMQRS Vulnerable Adults all
WMQRS Learning Disabilities all
WMQRS Cardiac and Stroke 1
Local Midwifery - LSA Annual 2010 2 Womens & T C Smith 3 CGE
Supervisory Inspection Childrens Rowson
Authority
Cancer Peer Cancer Services 2010 2 cancer T A 2 ME
Review services Rowson Trumper
www.urscertifi ISO9001:2000 & ISO Apr-09 RSH ME
cation.com 13485:2003 (Medical
Devices)
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MHRA Good Manufacturing likely 3 Pharmacy S Evans B McElroy Possibility of inspection CGE /
Practice March 09 ME
CPA Surveillance inspections 23.2.10 microbiology ME
CQC IR(ME)R unknown 3 Radiology T A Kent 1 Possibility of inspection ME
Rowson
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